Provider Demographics
NPI:1699197517
Name:WAGG, SAMUEL (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:WAGG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 UNIVERSITY AVE STE C203
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3361
Mailing Address - Country:US
Mailing Address - Phone:619-295-9791
Mailing Address - Fax:
Practice Address - Street 1:1010 UNIVERSITY AVE STE C203
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3361
Practice Address - Country:US
Practice Address - Phone:619-295-9791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-11
Last Update Date:2014-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32766111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor